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Community Care HUB Referral Form

Community Care HUB Referral FormCenter for Population Health2022-01-31T19:53:50+00:00

Referral Consent *

Individual has given consent to share the below information with the Community Care HUB for the purpose of enrollment into the care coordination program.

Referral Eligibility (check one) *

Pregnant; lives in Cambria or Somerset county; receiving or eligible for Medical Assistance

Pregnant; lives in Cambria or Somerset county; diagnosed with Gestational Diabetes

Parenting (0-18 Months); Lives in Cambria or Somerset County; eligible for or receiving Medical Assistance

Parent or Guardian of Greater Johnstown Elementary School student (attendance barriers, academic barriers, connection to community resources)

Parent or Guardian of Somerset Area School District student (attendance barriers, academic barriers, connection to community resources)

Twin Lakes

Referral Name (Primary Caregiver, if child)

First Name *

Last Name *

Referral Date of Birth (if known):

Referral Address

Referral Phone # *

If School District, please list each child's name, grade level, and needs below:

Referral Insurance Status *

Uninsured

Medicare

Commercial

Unknown

Other

Medicaid

(If Medicaid, choose 1 of the 4 options below)

Highmark Wholecare

UPMC 4 U

Health Partners

AmeriHealth

Health Insurance ID Number (if applicable)

Referral needs help with connections to (check all that apply) *

Developmental referral

Education

Employment

Family Planning

Food Security

Housing

Health insurance

Healthcare (Physical, Behavioral, SUD, Oral)

Medication Assistance

Social Services

Transportation

Other

Notes

If pregnant, who is the OB Provider and what is the participant's estimated due date?

Person Completing this Form

First Name

Last Name

Name of CHW who Referred

Referring Provider/Agency (if not self-referral)

Phone # of Person Completing this Form *

Email of Person Completing this Form

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